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Please print or type.(Form designed for use on elite(12-pitch)typter.) • Form Approved.OMB No.2050-0039 UNI�ORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tucking Number WASTE MANIFEST 9 ! Generators A �� v S.Generators Name and Mailing Address Site Address dfierent than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - ga 9b.U.S.DOT Descriidon(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unci HM and Packing Group If any)) No. Type Quantity WtNd. 13.Waste Codes 1... K aO w Z 2. W (D 3. 4. 14,Special Handling Instructions and Additional Information 15. GENERATOTSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classfied,packaged, marked and Iabeledlplaczrded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the tenns of the attached EPAAcknavledgment of Consent. I cemly that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generato'%ORerors Printed/Typed Name Signature'" - Month Day Year —a 16.international Shipments - - - - i ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: _ Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials KTransporter 1 Printedflyped Name Signature Month O Day Year N - zQ Transporter PrintedlTyped Name Signature Month Day Year K F 18.Discrepancy -�--, 18a.Discrepancy Indicabon Space ❑ Quantity yp— ❑Residue ❑Partial Rejection ❑Full Rejection MAY0 2 7G17 MandReference Number: rr- 18b.Alternate Facility(or Generator) U.S.EPA ID Number J ENWRONM ENTAL F iTH LL Faciliq/s Phone: PEWAIMEPAGES W 18c.Signature tr Attemate Facility(or Generator) Month Day. Year !Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Fablity Owner or Operator:Certification of receipt of hazzI materials covered by the manifest except as noted in Item 18a Pdnted7Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY